Contemporary Dance/Fort Worth
SCHOOL REGISTRATION FORM
A separate registration form must be completed for each student:  PLEASE PRINT LEGIBLY.

Today’s Date: ______________________________

Student Name (legal name):   _____________________________________________________

Nickname (if any) that prefer to be called:____________________________________________

At the time of registration I am requesting to be enrolled in the following classes/workshops:___________________________________________________________________________

Student Contact Information:

Street Address: __________________________________________________________

City, State: ______________________________	Zip Code: _____________________

Home phone: ____________________________________

Work phone: __________________________________ for ________________________ (name, if parent)

Cell phone: __________________________________ for _________________________ (name, if parent)

e-mail address: ___________________________@__________________

Birth Date: _______/_______/________		Age at time of registration: ________________

___  Female
___  Male

If enrolled in school:
	Grade (if applicable): ___________ School attending: ____________________________________

	University Dance Majors (list school and department): ____________________________________

If student listed above is a “minor”:
Father’s Full Name/or other legal guardian: ____________________________________________

Address: _________________________________________________________________________

Phone: ______________________________ (if different than above)

Mother’s Full Name/or other legal guardian: _____________________________________________

Address: __________________________________________________________________________

Phone: ____________________________________ (if different than above)

EMERGENCY REFERENCE:
Emergency Contact Number:
For “minors” please list at least one person other than the parent/guardians listed above.  
	For “adults” please list two emergency contacts.

Name:  ______________________________________    Work Phone: ___________________________	 	
Home Phone: _______________________  	          Cell Phone:_____________________________
		This person’s relationship to the student: _____________________________________

Alternative Emergency Contact:
Name: _______________________________________    Work Phone:___________________________
Home Phone: _______________________  	           Cell Phone:____________________________
		This person’s relationship to the student: _____________________________________

PHYSICIAN INFORMATION

Physician:  ____________________________________________________

Physician Address:  ____________________________________________

City: _______________________ State:  _______  Zip: ________________

Office Phone:  _____________________________

Important Medical History:
	Please list any allergies, regularly consumed prescription medications, or physical conditions which you feel would be important to medical personnel if you required emergency medical attention.______________________________________________________________________________________________________________________________________

I have broken bones in (please list location and side of body): ________________________________________________________________________________

I have had major surgeries or injuries which impact my ability to move (list type, location, and side of body):
______________________________________________________________________________________________________________________________________

Other helpful info for your teachers:

I have been diagnosed with disabilities which may impact my performance: _____________________________________________________________________________________________________________________________________

I am:   	_______ right handed
	_______ left handed

Years of previous dance study in:
	modern dance ____________				ballet __________________
	tap _____________________				jazz ___________________
	hip hop _________________ 				African _________________
	drill team _______________				other (what and years)__________

How many hours of exercise (including other dance classes) do you participate in each week?  ________________

Please list:
          ACTIVITY					FREQUENCY 			       	          SINCE WHEN?

_____________________		________________________		_____________________
	
_____________________		________________________		_____________________

_____________________		________________________		_____________________

What do you hope to achieve by participating in these classes? ___________________________________________

_________________________________________________________________________________________

I used to participate in other forms of exercise/sports:______________________________________________________

REFERRED BY:
(Please check all that apply.)

    	___ Yellow Pages       

___ Mail        

___ Friend: _____________________________________     

___ CD/FW Website  

			___  Advertisement in Fort Worth Child

			___ Advertisement in other publication (please list name of publication)
				_________________________________________

			___  Other _______________________________________

Contemporary Dance/Fort Worth
Waiver of Liability

I, _______________________________________, agree to indemnify and hold Contemporary Dance/Fort Worth (CD/FW), and the Texas Boys Choir, Inc., (operator of the Fort Worth Academy of Fine Arts), its program, staff, agents, representatives, employees and or any person or place that holds rehearsals or performances related to activities for CD/FW, harmless for any damages incurred now, or during the term of this agreement, from any injury of any kind resulting from my participation in CD/FW programs and activities.  I understand that in case of illness, injury, accident, or any other damage to my person or property while participating in these programs which may require attention by a physician and/or hospitalization, I will bear the expense personally or by insurance that I have provided for myself.  Any other cost or damages resulting from my participation in CD/FW programs, such as the cost of transportation by an emergency vehicle or damages to third persons, is also to be paid by me or by my own insurance.

_____________________________________________________________
Printed name of adult student (OR authorized parent or guardian of “minor” student)

I also agree to indemnify on behalf of a “minor” student in my care:

______________________________________________________________
Printed name of “minor” if applicable

_______________________________________________________________________________________________
Signature of adult student (OR parent or guardian of “minor” student)		Date Signed

Agreement of Classroom Protocol
	I understand that the accepted practice and methodology of professional dance training entails “hands on” and other forms of physical contact with instructors and other students, and that this is necessary for a student to learn at an appropriate pace.   I understand that if there is currently, or ever would be, any reason why I or my children/family members should not be touched, or should only be touched in a specific way, that it is my responsibility to inform EACH instructor as to what is acceptable, and to discuss any related physical or mental issues with them.
______________________________________________________________________________________________
Signature of adult student (OR parent or guardian of “minor” student)			Date Signed

Statement of Physical Condition and Personal Responsibility
	I hereby agree that I, or the above “minor” student for which I am responsible, is in good physical condition, and receives appropriate medical treatment and annual check-ups, and has clearance from a doctor to participate in an exercise program.  I understand that it is my responsibility to receive clearance from a medical doctor for any physical conditions that may be of concern, may hinder classroom performance, or may place me (or the above student) in unnecessary physical danger.  I understand that it is always my responsibility to communicate with the instructor as to injuries or illnesses which may impact classroom participation, and that ultimately I (or the above student) can choose not to participate in any portion of a class if necessary.
______________________________________________________________________________________________
Signature of adult student (OR parent or guardian of “minor” student)			Date Signed